Blood and Tears in Orlando
On June 12 of this year, a lone gunman entered Pulse, a gay nightclub in Orlando, FL, and carried out one of the deadliest mass shootings in U.S. history. The attack left 49 dead and 53 others badly injured. The wounded needed blood, and lots of it, which put a severe strain on an already taxed supply. In the days after the attack, rumors circulated that in light of the demand and due to the nature of the attack, Orlando area blood banks might be ignoring the FDA’s ban on donations from sexually active gay men. When news of the lifted restrictions on blood donation surfaced, it was accompanied by a sense that perhaps the LGBT community’s grief might be alleviated by knowing that their blood could be given to save innocent lives. In the end, however, it turned out that the rumors about gay blood donation were indeed just rumors.
Sadly, this is not the first time that a violent act of mass murder and terrorism has sparked debate surrounding the blood ban. In the days following the September 11 terrorist attacks in 2001 a similar sequence of events unfolded as Americans flocked to blood banks to contribute to the nation’s blood supply. For many young gay men it was the first time they learned that their blood was not wanted. “When I called the Red Cross and explained that I’m gay,” reported a young man to The Advocate, “I was told [not to come in] if I’m sexually active.”
Things have changed since 2001, however. Gays and lesbians have won the right to legally marry and adopt children, anti-discrimination bills have passed across the country, and “Don’t Ask, Don’t Tell,” has been repealed. While acts of homophobic and transphobic violence continue and are devastating, they are part of an angry but ultimately losing backlash against the very real gains that the LGBTQ community has undeniably made over the past decade. This is due, in no small part, to the expanding acceptance of sexuality as a fundamental, and perhaps even a defining, aspect of human identity – as intimate and important to our lives and our wellbeing as the blood in our veins.
Since the Red Cross began its National Blood Donor Service during World War II, blood donation has been entangled with notions of identity, citizenship and belonging. When the Red Cross began collecting blood for U.S. servicemen, African Americans were turned away from blood banks, only to have their blood segregated from the blood of white donors; the need for donations could not overturn racist fears over “mixing” blood. In the 1980s, Haitians also found themselves banned from the U.S. blood supply, this time due to fears of HIV/AIDS. By 1990, however, the Haitian community had grown politically powerful enough to push back and the ban on their blood was removed. Over time, Americans became less and less tolerant of donor policies that banned groups of people based on their identity, and screening guidelines moved towards the identification of populations based on “risk behaviors.”
In the U.S. and in many countries throughout the world, male-male sex has historically been and remains characterized as the most risky form of sex for the transmission of disease, especially HIV. This led to the category “men who have sex with men” (MSM), which served as a way for public health authorities and policy-makers to group individuals deemed at especially high risk for HIV. This terminology, however, suffers from several shortcomings that have fueled controversy and criticism in the context of blood-banking policy. First, the category of MSM misses actual risk behaviors. Gay men who practice safe sex and those who are in monogamous relationships, for example, do not share the same HIV risk as those who do not practice safe sex and who have multiple partners.
The flip side of this is that the categorization of MSM as inherently risky not only stigmatizes gay sex, but it also creates a false perception that heterosexual sex is inherently less risky. Of course unprotected sex with multiple partners and anal sex can occur in heterosexual pairings as well, and yet current U.S. blood screening guidelines overlook these risks while overemphasizing the risks of gay male sexual relationships. This false dichotomy of risk can extend to the falsehood of the homo/hetero binary as well. In other words, the FDA’s calculations of risk depend on the false assumption that MSM only have sex with other MSM.
When risk calculations, for example, suggest that lifting the MSM ban would increase the risk of HIV-transmitted transfusion from 1 in 1.5 million to 1 in 375,000, those risks are calculated based on the assumption that the MSM donor ban actually works, and that MSM self-identify, self-screen, and remain sexually isolated from heterosexuals. Case studies and data have shown for years, however, that these assumptions are false and that for a variety of reasons MSM, particularly those who are at high risk for HIV, are not effectively screened out from donations. One of the more recent transfusion-transmitted cases of HIV in the U.S., for example, came from a heterosexual-identified married man who had not considered himself at high-risk even though he had frequent sexual encounters with men and women outside of his marriage.
This latter point highlights yet another significant problem with using male-male sexual activity as a screening category: it ignores the multiple ways in which sexual behavior and identity intersect in people’s actual lives. Multiple studies of male sexual behavior, HIV, and blood donation have demonstrated that there are significant numbers of men who engage in sex with other men but who do not identify as gay or bisexual and who may also have sexual relationships with women. When the FDA first began reconsidering its lifetime ban on MSM donors back in 1997, social scientists were just beginning to grapple with these complexities. During a 1997 meeting of the Blood Products Advisory Committee, epidemiologist Lynda Doll presented the findings of a CDC follow-up study of donors whose blood had tested positive for HIV. Of the 174 HIV-positive donors in the study, 70% reported having engaged in male-to-male sex within the prior year, despite having responded negatively to the donor-screening question about MSM contact at the time of their donation. Despite the high rate of MSM activity, only 50% of this sample identified as gay or bisexual during follow-up questioning.
As Doll argued, the men most likely to respond accurately to the screening question about male-to-male sex are those who identify as gay or bisexual. Ironically, and problematically from a public health standpoint, these self-identifiers are also the segment of the MSM population who are least likely to engage in risky behaviors since community outreach, support, and services target the LGBTQ community. MSM who do not identify as homosexual or bisexual have actually been shown to be more likely to engage in unprotected sex with men and women, and they remain underserved by outreach materials and services.1
In addition to the questionable precision of the MSM donor ban, the policy causes harm to the gay community by reifying the stigmatization of male-male sex as inherently risky and pathological. In practice, though perhaps not in intent, the MSM ban targets a group of people based on a shared identity. This kind of discrimination became unacceptable for policies that historically excluded Black Americans and Haitians, and it seems that in the march towards equal rights for LGBTQ Americans, it ought to become unacceptable in this form as well. While public health agencies have an obligation to protect the blood supply from dangerous pathogens, they also have an obligation to refrain from causing undue injury and harm against a marginalized minority. The time seems ripe for developing policies that can address both of these obligations without sacrificing one for the other.
So what are the alternatives? In other countries, personalized risk assessment, or the “Assess and Test” method, has been implemented. After Italy adopted this approach, researchers there found that the policy resulted in no disproportionate increase in HIV-seropositive donors who were MSM compared to heterosexuals. Other suggestions for revising the screening involve moving away from identity-based screening questions towards more specific questions about safe-sex practices, number of partners, and whether or not the potential donor engages in unprotected anal sex.
The exclusion of “men-who-have-sex-with-men” in blood donor policy relies on an inadequately constructed risk category that, in practice, acts to invalidate gay men’s claims for biologic citizenship by insisting that male-to-male sex is strictly a “behavior” and not part of a larger identity. At the same time, the reality that male-to-male sex is linked to an explicitly “gay identity” in American culture creates a situation where those who do not see themselves as gay also do not consider themselves part of the category “men-who-have-sex-with-men,” regardless of their actual sex practices. The end result is a donor screening policy that leaves out self-identified donors who are the least likely to be HIV-positive while potentially missing those at greatest risk for infection. The one-year deferral may have been a step in the right direction, but it continues to leave gay men on the margins, stigmatizes male-male sex, and may even leave the blood supply inadequately protected against seropositive donors. The inability of gay men to donate blood for transfusion into the bodies of LGBTQ victims of a homophobic gun attack brings these tensions and inadequacies into relief in a horrific and powerful way.
Notes
- Karolynn Siegel, et al., “Sexual Behaviors of Non-gay Identified Non-disclosing Men Who Have Sex with Men and Women,” Archives of Sexual Behavior (2008) 37: 720-35. Return to text.
Jessica Martucci is a researcher at Philadelphia’s Science History Institute in the Center for Oral History where she leads projects on diversity and inclusion in STEM(edicine). She is the author of Back to the Breast: Natural Motherhood and Breastfeeding in America (University of Chicago Press, 2015) and has published numerous articles and essays that examine intersections between the history of motherhood, science, medical ethics, disability, and religion. She is also a member of the International Working Group on the History and Ethics of Medicine and Religion at the Catholic University of Leuven in Belgium.